Treatment for superficial infusion thrombophlebitis of the upper extremity

Background

Superficial thrombophlebitis is an inflammatory condition of the veins just below the surface of the skin. The development of superficial thrombophlebitis frequently complicates the insertion of needles into the veins for catheters to give medication or fluids in hospitalised patients. The best treatment for these blood clots in the hands and arms remains unclear. While local treatment has the potential to improve the painful symptoms and patient discomfort, it may not prevent complications, including infection or the extension or transit of the clot into the deep vein system.

Study characteristics and key results

In the current review, which looked for studies up to April 2015, we identified 13 studies involving 917 participants. Eleven studies evaluated topical treatments (medication applied to the skin), two trials studied an oral treatment, and two studies assessed a parenteral treatment (via injection or infusion). Seven studies used a control group that received no treatment or a placebo, whereas all others also or solely compared two active treatment groups. No study evaluated the effects of ice or the application of cold or hot bandages. Overall, topical treatments resulted in a higher and faster improvement of the clinical signs and symptoms compared to placebo or no intervention. Reporting on safety data was limited, with no available information on some treatments (notoginseny creams, parenteral low-molecular-weight heparin or defibrotide). Although some studies reported on harmful side effects with topical heparinoid creams, Essaven gel or phlebolan, the trials were too small in size to adequately measure any differences between treatments. Reported side effects of topical treatments consisted mainly of local allergic reactions. Only one study with 15 participants assessed anything other than localised control of the condition. That study reported on extension of the clot or symptomatic venous thromboembolism (when the blood clot breaks loose and travels in the blood stream), observing no cases when treated orally with non-steroidal anti-inflammatory drugs or with low-molecular-weight heparin. None of the studies reported on the development of suppurative or septic phlebitis (when pus is formed inside the vein or around the vein wall or both), catheter-related bloodstream infections or quality of life.

Quality of the evidence

Some of the included studies may have been biased due to design limitations, but we could not always assess this risk because the original researchers did not always provide enough information to judge. The overall quality of the evidence for each of the outcomes varied from low to moderate, mainly because the studies had design flaws or were very small. We could not analyse data on primary outcomes together because the trials examined different treatments, in different ways, looking at different outcomes. In short, the evidence about the treatment of acute infusion superficial thrombophlebitis is limited and of low quality, and we do not have enough information to recommend the use of any of the treatments studied.

Authors' conclusions: 

The evidence about the treatment of acute infusion superficial thrombophlebitis is limited and of low quality. Data appear too preliminary to assess the effectiveness and safety of topical treatments, systemic anticoagulation or oral non-steroidal anti-inflammatory drugs.

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Background: 

Although superficial thrombophlebitis of the upper extremity represents a frequent complication of intravenous catheters inserted into the peripheral veins of the forearm or hand, no consensus exists on the optimal management of this condition in clinical practice.

Objectives: 

To summarise the evidence from randomised clinical trials (RCTs) concerning the efficacy and safety of (topical, oral or parenteral) medical therapy of superficial thrombophlebitis of the upper extremity.

Search strategy: 

The Cochrane Vascular Group Trials Search Co-ordinator searched the Specialised Register (last searched April 2015) and the Cochrane Register of Studies (2015, Issue 3). Clinical trials registries were searched up to April 2015.

Selection criteria: 

RCTs comparing any (topical, oral or parenteral) medical treatment to no intervention or placebo, or comparing two different medical interventions (e.g. a different variant scheme or regimen of the same intervention or a different pharmacological type of treatment).

Data collection and analysis: 

We extracted data on methodological quality, patient characteristics, interventions and outcomes, including improvement of signs and symptoms as the primary effectiveness outcome, and number of participants experiencing side effects of the study treatments as the primary safety outcome.

Main results: 

We identified 13 studies (917 participants). The evaluated treatment modalities consisted of a topical treatment (11 studies), an oral treatment (2 studies) and a parenteral treatment (2 studies). Seven studies used a placebo or no intervention control group, whereas all others also or solely compared active treatment groups. No study evaluated the effects of ice or the application of cold or hot bandages. Overall, the risk of bias in individual trials was moderate to high, although poor reporting hampered a full appreciation of the risk in most studies. The overall quality of the evidence for each of the outcomes varied from low to moderate mainly due to risk of bias and imprecision, with only single trials contributing to most comparisons. Data on primary outcomes improvement of signs and symptoms and side effects attributed to the study treatment could not be statistically pooled because of the between-study differences in comparisons, outcomes and type of instruments to measure outcomes.

An array of topical treatments, such as heparinoid or diclofenac gels, improved pain compared to placebo or no intervention. Compared to placebo, oral non-steroidal anti-inflammatory drugs reduced signs and symptoms intensity. Safety issues were reported sparsely and were not available for some interventions, such as notoginseny creams, parenteral low-molecular-weight heparin or defibrotide. Although several trials reported on adverse events with topical heparinoid creams, Essaven gel or phlebolan versus control, the trials were underpowered to adequately measure any differences between treatment modalities. Where reported, adverse events with topical treatments consisted mainly of local allergic reactions. Only one study of 15 participants assessed thrombus extension and symptomatic venous thromboembolism with either oral non-steroidal anti-inflammatory drugs or low-molecular-weight heparin, and it reported no cases of either. No study reported on the development of suppurative phlebitis, catheter-related bloodstream infections or quality of life.

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